Elizabeth Demers Lavelle

Operative Delay for Orthopedic Patients on Clopidogrel (plavix): A Complete Lack of Consensus

BACKGROUND : Because of its irreversible nature, Plavix (clopidogrel) has become a double edged sword in the care of some of our sickest patients, particularly when surgical intervention is required. Platelets exposed to a single dose of clopidogrel are affected for the remainder of their lifespan and recover normal platelet function at a rate consistent with platelet turnover, which is within 5 days to 7 days (1-3) with the generation of new platelets not influenced by the drug; however, delay of surgical fixation for orthopedic patients, particularly patients with hip fractures may lead to increased morbidity and mortality. METHODS : A Web-based survey was created and administered to the program directors of academic orthopedic surgery programs. RESULTS : Seventy-three percent of orthopedic residency programs responded that waiting 3 days or less for urgent but nonemergent operative interventions on patients on clopidogrel is acceptable with 23% feeling that no delay at all is necessary. For emergent surgery, the vast majority of programs 66 (89%) reported no delay to the operating room for patients on clopidogrel. CONCLUSIONS : The majority of orthopedic surgery residency programs who responded to the survey wait less than 3 days for urgent surgery and do not delay surgery for emergency cases for patients on clopidogrel. At this point we feel that an early intervention that occurs within approximately 2 days, with the acceptance of the possibility of increased blood loss is in the patients best interest. Based on the reviewed physiology, a perioperative platelet transfusion may be of some benefit as the transfused platelets would be effective in forming a viable plug.

Mortality Prediction in a Vertebral Compression Fracture Population: the ASA Physical Status Score versus the Charlson Comorbidity Index.

Background Morbidity and mortality scores are useful to control for medical comorbidities in study populations where either effects of an illness or benefits of a treatment are examined. Our study examined if a direct relationship existed between the American Society of Anesthesiologists Physical Status (ASA) score and the Charlson Comorbidity Index (CCI) in an osteoporosis population where patients had sustained a vertebral compression fracture. Methods A retrospective chart review of patients with osteoporotic compression fractures treated by the same orthopedic surgeon between June 2000 and June 2004 was performed. The primary endpoint was death by the close of the study period (September 2006). A board certified Anesthesiologist blindly assigned all of the ASA scores as well as the Charlson Scores independently in a blinded manner. All patients were assumed to be undergoing surgery as they were assigned. A statistical relationship was examined between ASA and CCI scores through a cross table analysis with chi-squared testing as both scoring systems were considered categorical. A Pearson correlation was completed to examine the quality of a linear relationship between the categorical variable ASA compared to the continuous variable Charlson. A value of p < 0.05 was considered significant. Results Ninety patients elected conservative therapy with oral analgesics and an orthosis, while 94 patients elected for kyphoplasty. The CCI by log rank testing was not significant (p= 0.2027) for the surgery population; however, the test resulted in a highly significant value (p = 0.0161) in non-operative population. The ASA Score was correlated with significance to mortality (p= 0.0150) for the surgery population, while the test was not significant (p = 0.1439) in non-operative population. Treating both ASA and CCI scores as categorical variables, a relationship between them was examined and found to be highly significant (p= 0.000001) meaning patients with low ASA scores were likely to have low CCI scores. Conclusion The ASA score was predictive of mortality in a surgical population, while CCI was highly predictive of mortality in a non-surgical population. There is great agreement between the CCI score and the ASA score, reflecting that anesthesiologists subjectively consider the same elements of the patients medical history when assigning ASA scores as the CCI objectively uses. This was a Level III Study.

Safety and Efficacy of the Use of Intrathecal Morphine for Spinal Three Column Osteotomy

Introduction The use of intrathecal morphine has the potential to help alleviate the pain that patients experience undergoing spinal surgeries. Complications can cause immobilization, which can lead to vascular thrombosis and ileus. Studies have shown epidural analgesia significantly lowered postoperative pain scores in scoliosis surgeries. Intrathecal anesthesia has been shown to have good pain control over the initial 24-hour postoperative period. Purpose Determine if intrathecal morphine would reduce postoperative pain with minimal side effects. Methods The surgical case logs from three spinal deformity surgeons from a single academic medical center were reviewed retrospectively. This included cases where more than five levels of fusion occurred and surgery involved an osteotomy. The records of 17 patients were queried, and patient and surgical data were collected. The patients were divided into two groups: eight patients were administered intrathecal morphine and nine patients received no morphine. Postoperative pain scores were obtained hourly over the initial 24 hours postoperatively by nurses trained to obtain pain scores from the Numeric Pain Rating Scale. In addition, the rates of any noted side effects were recorded. Analysis of variance (ANOVA) and Fisher’s exact tests were used to calculate any statistical significance with p < 0.05 considered to be significant. Results The maximum and total 24-hour postoperative pain scores had a mean of 5.6 (standard deviation = 4.2; p = 0.4266) and 69.3 (standard deviation = 57.8; p = 0.9189), respectively, for patients administered intrathecal morphine. The patients who did not receive intrathecal morphine had total pain scores of 3.9 (standard deviation = 4.5) and 65.7 (standard deviation = 79.7), respectively. Though the results were not statistically significant, there was a potential trend toward decreased in pain mean scores in the first 10 hours for the intrathecal morphine group. There was no statistical difference in the rate of side effects between patients. Conclusions The use of intrathecal morphine did not significantly appear to reduce postoperative pain in patients when compared to intravenous or oral narcotics. There was a potential trend in a reduction in postoperative pain during the first 10 hours postoperatively, but this did not reach a statistically significant value and did not hold up after the first 10 hours postoperatively. However, it was noted that intrathecal morphine was safe to use in postoperative spinal deformity surgery as no statistical significance in side effects was noted.